Correcting plugs in the Crown - Vertex
Area

Plugs placed in the crown and vertex can be managed with
PR & R as well. The main difference in managing plugs
in this region is the determination of whether they should
be removed entirely or simply reduced and the surrounding
area grafted. The deciding factor is based on patient preference,
the degree of crown vertex alopecia, and the amount of occipital
donor supply. In cases where plugs are to be removed and no
additional grafting is planned, punches size equal to or slightly
larger than the plug should be used. When plugs are removed
the residual scar that remains in the crown alopecia can be
imperceptible or can remain with variable degrees of prominence.
Patients requesting removal of plugs in the crown region need
to be aware of the unpredictability of the plug excision scar.
In most cases, removal of the plugs with additional grafting
is a more desirable option since the remaining plug excision
scars are well hidden by the recycled grafts.

When crown vertex plugs are to be reduced and recycled the
eccentric plug excision technique is similar to that applied
to the anterior hairline. Usually the most posterior 1 cm
of plugs in this region are reduced, sutured, and recycled.
Recycled plug grafts and newly harvested grafts from the occipital
donor area are transplanted in areas of alopecia between the
existing plugs and closed reduction sites. Instead of creating
an irregular anterior hairline a gentle taper zone of grafts
containing 1-3 hairs per graft is created extending posteriorly
from the reduced line of plugs. This buffer of smaller grafts
softens the transition between the bald non-transplanted posterior
scalp and the transplants in the crown vertex area.

Case 3: (fig 6) 38-year-old male
who was dissatisfied with the anterior and posterior view
of his hair transplant. The approach to correct the posterior
aspect of his forelock was to perform plug reductions and
recycling to the posterior 3 cm of plugs and graft into the
surrounding areas of alopecia. In addition a posterior zone
of grafts was developed to soften the transition between the
total alopecia of the occipital region and the dense appearance
of the plugs in the mid crown. Approximately 25 plugs were
reduced and 800 grafts containing 1-3 hairs were transplanted
in two sessions. Results are seen 5 months following the second
procedure.

Fig. 6. Results seen in a 38-year-old man
who underwent two sessions of plug reduction and recycling
to the crown, as well as grafting to the posterior
fringe, to create a soft transistion to the vertex
alopecia.

Case 4: (fig 7) 45-year-old male
who had plug transplants to the frontal and anterior crown
region. The anterior hairline was the first cosmetic priority
for the patient and following two sessions of PR&R to
this area he requested a similar approach to the posterior
region. A leading edge of approximately 18 plugs were reduced,
closed, and recycled. A posterior transition zone of 400 grafts
containing 1-2 hairs per graft were placed posterior to the
plug reduced area. The results are seen 10 months following
this single session in the crown area. The patient is likely
is undergo an additional procedure in this area

CLICK IMAGES FOR CLOSER
VIEW

Fig 7. 45 year old male who underwent a single
session of PR &R with grafting in the crown region.
A pre existing scar on the left became more noticeable
when the plugs were thinned out.